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A Physical Therapy Approach For low Back Pain

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Introduction Approximately 60-80% of population will have lower back

pain at some time in their lives, and one –half will have recurrences.

2nd most common cause for P-T visit Potent cause of absence from work 60% of LBP suffers experience functional limitation or

disability as a result of their pain 90 % of cases of LBP resolve without treatment within 6-12

weeks 40-50 % LBP cases resolve without treatment in 1 week 75 % of cases with nerve root involvement can resolve in 6

months

3Steven Stoltz, M.D.

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Causes Musculoskeletal Degenerative Rheumatic Neoplastic Referred Infection Psychological Metabolic

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Musculoskeletal Ligamentous Muscular Facet joint Sacroiliac strain Prolapsed disc Fracture Scoliosis

Degenerative Osteoarthritis Spondylosis

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Rheumatic Rheumatoid Arthritis Ankylosing Spondylitis

Neoplastic Primary Secondary

Prostate Lung Renal Breast Thyroid

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Referred Pain Gynaecological Renal Other abdominal

Infection TB Osteomyelitis Herpes Zoster

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Psychological Depression Malingering

Metabolic Osteoporosis Paget’s Osteomalacia

Predisposing factorsPostural stressWork related stressDisuse and loss of mobilityObesityDebilitating conditions

Precipitating factorsMisuseOveruseAbuse or trauma

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Types of pain Based on source

Mechanical Discogenic

Based on affected region Local Referred

Based on nature Transient Acute Chronic

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History

Sometimes a clear cause but often not In a young, fit person then usually:

muscle or ligament strain facet joint problem prolapsed disc

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Muscle or ligament strain Usually can give you the cause Related to posture Episodic Pain worse on movement, helped by rest

Facet Joint

- Sudden backache with a simple movement “I was just picking up a coin off the floor”- Often flexion with rotation- May have heard a click

Prolapsed Disc

-Shooting pain-Pain radiating down the leg below the knee-Aggravated by coughing/sneezing-Usually sudden onset and often no trauma

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Red Flags in the History Retention of urine or incontinence Onset over age 55 or under 20 Symptoms of systemic illness - weight loss, fever Morning stiffness Severe progressive pain A prior history of cancer Intravenous drug use Prolonged steroid use

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Examination Observation Palpation Movements Straight leg raising Femoral stretch test Power Sensation Reflexes

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Forward bending

Hands are pushing in opposite direction

Tissues from skin to central core Elongate posterior Compress anterior

Assessing lumbo-pelvic congruency Palpation from cervical spine

to pelvis

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Back Examination

Nerve tension signs Nerve compression signs

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Examination of back pain

Supine Testing Passive hip flexion Faber position Straight leg raise (SLR) Force is directed to right femur

Posterior to anterior force directed to femur • In flexed and vertical position

Passive knee flexion in a prone position Passive internal and external hip rotation

knee at 900 of flexion

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Passive hip flexion

Hip hyperflexed Lumbar spine flattened

Over 900 of flexion

Force transmission To extensor of hip

Posterior rotary movement on ilium

Spinal flexion

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Straight leg raise (SLR)

Straight leg raised Femoral flexion Adduction Internal rotation Increase in tensile

force On sciatic nerve

Related to ischial tuberosity

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L4/5 Prolapse Straight Leg Raising reduced Ankle Jerk present Weakness

Big Toe Foot Dorsiflexion

Sensory Loss Medial foot

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L5/S1 Prolapse

Straight leg raising reduced Ankle jerk absent Weakness

Plantar flexion Foot eversion

Sensory Loss Lateral foot

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Investigations For simple backache, age 20-50 <4 weeks

duration,no red flags - no x-rays necessary. Patients expect one.

X-ray: recent significant trauma recent mild trauma over 50 prolonged steroid use osteoporosis age over 70

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Investigations

Plain x-ray with FBC and ESR to rule out tumour, infection if red flags suggest likely

If red flags present and plain x-ray normal then bone scan, CT or MRI may still be indicated

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Acute Low Back Pain

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Nerve Root Pain

Unilateral leg pain worse than low back pain Radiates to foot or toes Numbness and paraesthesia in same distribution SLR reproduces leg pain Localised neurological signs - reflexes and

power

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Possible Serious Spinal Pathology Symptoms of systemic illness - weight loss, fever Morning stiffness Severe progressive pain A prior history of cancer Intravenous drug use Prolonged steroid use

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Cauda Equina Syndrome Sphincter disturbance Gait disturbance or widespread motor weakness

involving more than on nerve root or progressive motor weakness in the legs

Saddle anaesthesia of anus, perineum or genitals Needs emergency referral

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Red Flags (again)

Retention of urine or incontinence Onset over age 55 or under 20 Symptoms of systemic illness - weight loss, fever Morning stiffness Severe progressive pain A prior history of cancer Intravenous drug use Prolonged steroid use

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What to tell the patient

Increase physical activity progressively over a few days or weeks

Stay as active as possible and continue normal daily activities

Stay at work or return to work as soon as possible as beneficial

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Who to Refer

Nerve root pain not resolving after 4 weeks (Orthopaedics)

One or more red flags leads to credible evidence of serious pathology

Cauda equina syndrome Can have manipulation as long as no progressive

neurology

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Phases of Treatment Treatment of pain

Modalities Medication

Support the region Biomechanical counseling / rest

Continue support Begin non-destructive movement Decrease destructive behavior

Discontinue support Begin proprioceptive and kinesthetic strength training

Neuromuscular efficiency Dynamic stabilization

Establishment of limits Movement Loads Positions Frequencies

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Treatment Options Cryotherapy Thermotherapy

Superficial heating Deep Heat

Injection Therapy & Soft tissue injections Electrotherapy

Transcutaneous electrical nerve stimulation (TENS) Manipulation Traction Massage Physical therapy and exercises Acupuncture Corsets and braces Surgerical treatment

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Postural education / body mechanics

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USING PROPER BODY MECHANICS

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Back Exercises

Strong evidence that back exercises do not produce any significant improvement in acute back pain

Moderate evidence that exercise programmes can improve pain and function in chronic low back pain

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Exercises Many programs available, but difficult to make any

scientific recommendations for one type versus another

Goals of exercises: Improves pain and function Decrease mechanical stress Increase strength and flexibility Improve posture and mobility

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- Two main practical Exercises are used in P-T clinics

1- Williams exercises: Strengthening exercises for the lumbar flexors with stretching the musculature and ligamentous structure of the extensors.

Flexion exercises are used to open the intervertebral foramina and facet joint.

2- McKenzie Exercises: Strengthening exercises for the lumbar extensors to reduce the derangement and centralise the pain

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Low Back Stretches

Knee to chest Double knee to chest

Lumbar rotation Lumbar rotation – leg extension – contralateral arm elevation

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Supine Hamstring – knee extended90 deg – normal length

Periformis stretch – pressing outward on crossed knee

Hip Flexor stretch – front kneeat 90 degrees

Deeper stretch – elevate arm on same side of extended leg

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ROM/Localizing/Strengthening

Prone on elbows Prone Press-ups pain free only

Multifidus engagement – activate TAExtend leg 2-3 inches off surface

Swimmers (Multifidus)Extend opposite arm/leg

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Strengthening - TA

Plank – activate TA – elevate on forearms - toes

3-point Plank – raise one foot

2-point plank – elevate opposite arm/leg

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Bridge – activation of TAPelvis level Bridge with SL extension

Switch legs without lowering trunk or pelvis

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Progressing difficulty